WORKERS’ COMPENSATION CLAIMS KIT

WORKERS¡¯ COMPENSATION

CLAIMS KIT

WELCOME!

Thank you for your Workers¡¯ Compensation business. This welcome kit is designed to make

the claims reporting and handling process smooth and efficient. We have also provided

information on additional programs and resources we offer to help your injured employees

recover and return to work as quickly as possible.

Should you have any questions regarding anything outlined in this kit or your policy, please

do not hesitate to contact us.

TABLE OF CONTENTS

About Protective Insurance

Claim Reporting Instructions

Claims Process

First Fill Prescription Information

Finding an In-Network Doctor/Pharmacy

Claim Review Information

Return-to-Work Programs

Controlling Your Experience Mod

WellCard Savings Program

Insurance Fraud Information

Loss Prevention & Safety Services

APPENDIX:

First Report of Injury or Illness Form

Wage Statement

Authorization to Release Medical Information Form

First Fill Prescription Card

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ABOUT US

We are Protective Insurance.

We¡¯ve been delivering high-quality, customized insurance products to our customers

since our founding. Our company has humble beginnings as an insurance broker based

out of Indianapolis. Eighty years later, we still proudly call Indiana home. With over 500

employees, all of our departments¨C including claims, customer service and loss prevention ¨C

are housed in a single corporate office.

We specialize in workers¡¯ compensation and transportation insurance. We are rated A+

(Superior) by A.M. Best and offer a range of flexible workers¡¯ compensation solutions for all

types of businesses.

At Protective Insurance, partnerships matter. The average length of time a workers¡¯

compensation policyholder has been with us is five years. As a valued customer, you are

more than just a policy to us¡ªwe are personally invested in your company¡¯s safety and

success.

Whether it is loss prevention training resources to help your business cultivate a culture of

safety, on-demand safety training or return-to-work program assistance, you can count on

Protective Insurance.

If claims should occur, you can rest assured that they will be handled with the attention and

precision they deserve due to our adjusters¡¯ low claim counts. With an average of 10 years¡¯

experience, our claims adjusters know the industry, and they know it well.

Throughout every facet of our business, we are dedicated to providing you with a

personalized, hands-on approach, going above and beyond the standard role of what you

would expect from your insurance company.

We thank you for the opportunity to be your partner in safety and risk, and look forward to

working with you.

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CLAIM REPORTING INSTRUCTIONS

If an employee or member of your staff suffers an employment-related injury or illness

that involves medical care or loss of work time, please submit all claims within 24 hours of

the injury or illness being reported to you. All new reports will be handled by experienced

professionals that specialize in First Reports of Injury. We anticipate that you will find them

knowledgeable, professional and helpful throughout the reporting process.

CLAIM REPORTING OPTIONS

Report a claim through any method 24 hours a day, 7 days a week.

Your company should report all claims.

EMAIL

FAX

newwcclaims@

(317) 715-9639

PHONE

ONLINE

Toll free: (800) 479-0981

claim

Email and Fax Claims

If you would like to report a new claim via email or fax, please complete and return the

First Report of Injury or Illness form in the appendix. Per the form¡¯s instructions, please

attach the additional requested information to your claim report, including a completed

Wage Statement form and a copy of the Authorization to Release Information form

signed by the injured worker. Both of these forms are also included in the appendix.

Authorization to Release Information

Submitting an Authorization to Release Information form expedites the processing of any

claim. Regardless of the method by which you initally report the claim to Protective, please

provide this form to your injured worker for his/her signature and return to us via email, fax

or postal mail.

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CLAIM REPORTING INSTRUCTIONS continued

Phone Claims

Please have the following information available when reporting a claim by phone:

Employee Information

? Name, address, Social Security number, age, sex, phone number and email address of

injured employee

? Name of employer, federal tax ID number, address, phone number and email address

? Hourly/weekly/monthly wage of injured employee

? Work schedule of injured employee (hours per day, days per week, start/end times)

Accident Information

? Date, time, location and description of incident (how, where, why)

? Part of body injured and type of injury (cut, scrape, burn, etc.)

? Name and address of physician and hospital where injured employee was treated

? Has the injured employee returned to work? If so, what was the date of return?

Was there lost work time involved?

? Did anyone witness the incident? Was anyone else involved in the incident?

? If applicable, terminal/station address, phone number and terminal/station manager name

? If applicable, information on vehicle that the injured employee was using (ID number,

type, etc.)

MY ACCOUNT

Looking for details about a specific claim or your claim history in one place? Protective¡¯s

online customer service system, My Account, allows our policyholders to view claim details as

well as loss run reports. Log on at my-account.

To obtain a My Account login, contact your agent.

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